Provider Demographics
NPI:1033254164
Name:JOHNSON, KELLY SUZANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:SUZANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28379 DAVIS PKWY
Mailing Address - Street 2:SUITE 801 CANTERA LAKES OFFICES-CLARUS CENTER
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3032
Mailing Address - Country:US
Mailing Address - Phone:630-355-3321
Mailing Address - Fax:630-393-0499
Practice Address - Street 1:28379 DAVIS PKWY
Practice Address - Street 2:SUITE 801 CANTERA LAKES OFFICES-CLARUS CENTER
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3032
Practice Address - Country:US
Practice Address - Phone:630-355-3321
Practice Address - Fax:630-393-0499
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005691103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist